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Psychiatry 2008 [ M A R C H ] 58LEGAL INSANITYAssessment of theInability to RefrainLEGAL INSANITYAssessment of theInability to RefrainO R I G I N A L R E S E A R C Hby ANDREW DONOHUE, DO; VINAY ARYA, MD; LAWRENCE FITCH, JD; andDEBRA HAMMEN, LCSW-CAUTHOR AFFILIATIONS: Dr. Donohue is from Forensic Psychiatrist, Delaware Psychiatric Center, NewCastle, Deleware; Dr. Arya is Attending Psychiatrist, Monmouth Medical Center, Long Branch, NewJersey; Dr. Fitch is Maryland Director of Forensic Services, Jessup, Maryland; and Ms. Hammen isChief, Systems Operation, Maryland Office of Forensic Services, Jessup, Maryland.by ANDREW DONOHUE, DO; VINAY ARYA, MD; LAWRENCE FITCH, JD; andDEBRA HAMMEN, LCSW-CAUTHOR AFFILIATIONS: Dr. Donohue is from Forensic Psychiatrist, Delaware Psychiatric Center, NewCastle, Deleware; Dr. Arya is Attending Psychiatrist, Monmouth Medical Center, Long Branch, NewJersey; Dr. Fitch is Maryland Director of Forensic Services, Jessup, Maryland; and Ms. Hammen isChief, Systems Operation, Maryland Office of Forensic Services, Jessup, Maryland.ADDRESS CORRESPONDENCE TO: Andrew Donohue, DO, Deleware Psychiatric Center,1901 N. DuPont Highway, New Castle, DE 19720; Phone: (302) 577-6490; Fax: (203)577-6498; E-mail: andrew.donohue@state.de.usKEY WORDS: insanity defense, not guilty by reason of insanity,irresistible impulseADDRESS CORRESPONDENCE TO: Andrew Donohue, DO, Deleware Psychiatric Center,1901 N. DuPont Highway, New Castle, DE 19720; Phone: (302) 577-6490; Fax: (203)577-6498; E-mail: andrew.donohue@state.de.usKEY WORDS: insanity defense, not guilty by reason of insanity, irresistible impulseABSTRACTMaryland’s test for a finding of legalinsanity (not criminally responsible[NCR]) allows a defendant to be foundlegally insane due to either a lack ofappreciation of wrongfulness(cognitive impairment [CI]) or lack ofability to refrain from illegal behavior(volitional impairment [VI]). During afour-year period, 1,446 defendantsunderwent in-depth (post screening)evaluations for the NCR plea atMaryland state hospitals. Of the 416defendants assessed as NCR by thehospitals’ court-appointed evaluators,44 (11%) were assessed as NCR dueto VI alone. Diagnostically, the VI andCI groups were similar. Criminalcharges were also similar, but the VIgroup was more likely to have beencharged with murder. Many of theforensic evaluators concluded that theVI group was unable to refrain fromillegal conduct based on considering anumber of factors, includingpsychiatric symptoms and thedefendant’s behavior as related to theoffense. Some evaluators’ reportsoffered an opinion, but did notadequately explain what data theyused to arrive at their conclusion. Thispaper examines the history of andrationale for a volitional test of insanity